Inpatient/Outpatient Medical Coder

Posterity Group; Cleveland (OH); On-site; USD 65,000 - 90,000; Full time

Job summary

Posterity Group is staffing Louis Stokes Cleveland VA Medical Center with In/Outpatient Medical Coders. The role requires coding across inpatient, outpatient, and surgical encounters, accurate linking of documents to veteran records, and timely processing within set deadlines.

Candidates must hold AHIMA or AAPC certification and have at least two years of VA facility coding experience, with strong knowledge of ICD-10-CM/PCS, CPT/HCPCS, and E/M guidelines. U.S.

Qualifications

• At least one current coding certification from AHIMA or AAPC (RHIT, RHIA, CCS, CCS-P, CPC, COC, CIC).
• Proficiency coding inpatient, outpatient, and surgical services across diverse records.
• Familiarity with ICD-10-CM/PCS, CPT, HCPCS and E/M guidelines.

Responsibilities

• Code inpatient and outpatient data, including surgical cases, within required timelines.
• Attach images to EHR elements and verify legibility and accuracy.
• Query providers to resolve documentation discrepancies per VHA processes.
• Perform QA on coding and ensure compliance targets (e.g., >95%).

Skills

Medical coding

AHIMA/AAPC certs

ICD-10-CM/PCS

CPT/HCPCS

PHI handling

Job description

Description

Posterity Group LLC is a veteran owned, service-disabled small business, headquartered in Rockville, MD, that specializes in federal government contracting and staffing. We are tasked with staffing Louis Stokes Cleveland VA Medical Center with In/Outpatient Medical Coders. The Medical Coder is expected to do the following:

• Accurately attaching images to the appropriate electronic health record elements.
• Verifying that images are uploaded correctly and are legible for viewing.
• Locating Financial Identification Numbers (FINs) and accurately linking documents to the correct veteran record.
• Indexing documents within the correct section, note title, date of service, and visit location.
• Performing 100% internal QA on all work before submission.
• Process Inpatient, Outpatient coding within five (5) calendar days of assignment, surgery coding completed immediately after the procedure when possible and no later than five (5) calendar days from the date coding is assigned, goal of greater than 95% compliance.
• Process all re-codes, rejects, and corrections without delay once reassigned, goal of greater than 95% compliance.

Requirements

• At least one current coding certification from AHIMA or AAPC (RHIT, RHIA, CCS, CCS-P, CPC, COC, CIC).
• A minimum of two (2) years of continuous professional coding experience in a VA facility comparable in size and complexity to VA Northeast Ohio Healthcare System, or equivalent.
• United States citizenship and proficiency in spoken and written English.
• Demonstrated ability to code across all major inpatient, outpatient, and surgical specialties.
• Demonstrate proficiency in applying appropriate coding conventions across all care settings, including inpatient, outpatient, professional services, and surgical encounter/FINs. Required competencies include ICD-10-CM, ICD-10-PCS, CPT, HCPCS, and E/M guidelines, or the applicable combination based on assigned coding responsibilities.
• Ability to query providers and resolve documentation discrepancies following the VHA Provider Query Process.
• Proficiency in Oracle Health coding processes and familiarity with legacy systems (VistA, CPRS, VIRR).
• Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation.
• Ability to read and understand the content of the health record, the terminology, the significance of the comments, and the disease process/pathophysiology of the patient.
• Ability to accurately perform the full scope of assigned coding, including ambulatory surgical cases, diagnostic studies and procedures, outpatient encounter/FINs, inpatient facility coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional services.
• Skill in interpreting and adapting health information guidelines that are not completely applicable to the work, or have gaps in specificity, and the ability to use judgment in completing assignments using incomplete or inadequate guidelines.
• Ability to meet or exceed 3 inpatient PTFs (to include professional and surgery services as applicable); 25 outpatient/prosthetics services encounter/FINs; 9 surgical services encounter/FINs (to include anesthesia and pathology as applicable) per day.
• Demonstrate ability to review all Service Connection and Service Authority questions (Service Connected, Agent Orange, Ionizing Radiation, Head and Neck Cancer, Military Sexual trauma and Combat Veteran) at the diagnosis level when prompted and assign to facility Utilization Review Nurse if appropriate.
• Exclude from coding information such as symptoms or signs characteristic of the definitive diagnoses, findings from diagnostic studies or localized conditions that have no bearing on current management of the patient.